Sedation..Your thoughts?

meandragonbrett · Mar 7, 2011

I would have left her exactly where she is and maybe added some dilaudid or fentanyl for pain control if needed.

detroitdano · Mar 7, 2011

Propofol and Versed are meant to accomplish the same task. There is no pain medicine on board there. What kind of sedation protocol were you following? We usually do Fentanyl and Versed, if that doesn't cut it, then Fentanyl and Propofol.

50 mcg/kg/min of Propofol is a ton to me. I've seen hardcore heroin withdrawal patients get snowed off of 15 mcg/kg/min. Perhaps with a pain med on board you could have even turned the rate down further. Granted she was exactly where you wanted her to be, that's a heavy amount of sedatives.

meandragonbrett · Mar 7, 2011

50 mcg/kg/min of Propofol is a ton to me. I've seen hardcore heroin withdrawal patients get snowed off of 15 mcg/kg/min.

I think it's not a lot...just dependent on your patient population. We routinely run prop at 100mcg+ and have ativan and haldol on board and have people awake and following commands to verbal stimuli.

catshowlady · Mar 7, 2011

I would have left it alone if she was comfortable, could follow commands, and was not grabbing for the ETT. Why snow them? I think it takes them longer to wake up if they are constantly snowed. I do turn the sedation up and snow them during their bath, so they aren't uncomfortable during the linen change, then turn them back down after we're done.

As far as how much sedation, each pt is different. I've had LOL's that needed 50mcgs of propofol plus some Versed to keep them comfortable and young folks that only needed 10mcgs to keep them sedated.

I think you did fine. :)

:paw:

CRNA1982 · Mar 8, 2011

Propofol and Versed are meant to accomplish the same task. There is no pain medicine on board there. What kind of sedation protocol were you following? We usually do Fentanyl and Versed, if that doesn't cut it, then Fentanyl and Propofol.
50 mcg/kg/min of Propofol is a ton to me. I've seen hardcore heroin withdrawal patients get snowed off of 15 mcg/kg/min. Perhaps with a pain med on board you could have even turned the rate down further. Granted she was exactly where you wanted her to be, that's a heavy amount of sedatives.

I must say that Fent and Midaz gtts are far superior than Fent and Prop for long term pts. in the ICU; you just have to give them what they need. We all know that Prop can be some nasty stuff for pts receiving it for longer than 24-48 hours. As far as 50 mcg/kg/min of Prop, it is NOT a lot. I often run Prop gtts at 100 mcg/kg/hr on soccer moms (Who enjoy their daily Martini or prn Xanax) having minor surgical procedures (Such as a removal of a small cancerous lesion or a D+C) along with Midaz and Fent combined. And these pts. are breathing spontaneously throughout without an OET.

ckh23, BSN, RN · Mar 8, 2011

I wouldn't have done anything. In fact I might have even started coming down on the prop and versed if she remained comfortable. I mean we have all seen patients that are wide awake on the vent with no meds and they have no complaints and tolerate the vent. From what you described it sounds like she could be weaned off of them and just have an order for prns if she became uncomfortable. She was bucking and wasn't trying to pull out ETT so why not try to wean the sedation and try and get the levo off. But then again it's also something that can be done during day shift (I rotate so I know what it is like on days and nights), sometimes it's just better to let them sleep and rest.

I don't see any issues with leaving her as is.

Da_Milk_of_Amnesia, MSN · Mar 8, 2011

Well thats what I was doing, obviously when she initially came she was tough to keep down, by the time i left to go home after 16 hours. The Versed was at 6, the propofol was at 40mcgs and the levo was at 2.5 and she was comfy.
Thanks for everyones responses.
Our sedations protocols call for either Versed, Ativan, or Propofol. Usually start with propofol and titrate to a max of 50mcgs/kg/min
The Versed and Ativan both have parameters to start at either 2 or 4mgs and the MDs can write their own max on those
Our Pain protocols call for Fentanyl, morphine..I wanna say there is one more that I am forgetting.
If I had to say what our mainstays are I would say Propofol and morphine are def our top combo. Trauma uses both alot, btu our intensivists stay with propofol and will had others if needed.

detroitdano · Mar 8, 2011

Well this thread was a learning experience for me. I've never seen someone on over 45 mcg/kg/min of Propofol that could follow commands. Propofol isn't used frequently, we have to try and max out Versed before switching up to Prop, but each time we have I've never seen anyone require a lot.

Mrs.Rollins, ASN, RN · Mar 9, 2011

With our population it's not uncommon for us to run 50-60mcg propofol, 9-10 midazolam, and Fentanyl or Dilaudid gtts and patients to still be awake and actively pulling at ETT/lines/Foleys. We get a lot of chronic drinkers and druggers.

tri-rn · Mar 10, 2011

while even sedated on 50mcgs/kg/min of propofol and 6 of versed was able to open eyes and follows commands and respond appropriately. I asked her several times if she was comfortable to which we nodded 'yes'. Her Peak pressures were all fine in, her HR was 90s-100s, which is better than the 110-120s she was when she got to me and her BP was now 100-110s which was better than the 70-80 when she got to me (septic, severe PNA).

Right here, you answered your own question. It sounds to me like you did fine :)

lvICU · Mar 13, 2011

I don't see anything wrong with letting a patient be "awake" on the vent as long as they are comfortable. Propofol dosing varies from patient to patient. In my experience 50 mcg/kg/min is an average dose. If she was stable and calm, I would have decreased the doses even more and you may have been able to titrate off the Levo.

There is a lot of research being done on the long-term effects of sedation in the ICU. There is some suggestion that use of benzos and other sedatives in the ICU population actually causes long-term defecits such as loss of memory and depression. Just some food for thought.